Clinical Recommendations for Reducing the Risk of Cognitive Decline

Abstract As much as 40% of dementia cases can be attributed to modifiable risk factors (Livingston et al., 2020). Much of that risk-reduction can be accomplished by changing behavior in midlife. In light of the emerging evidence that dementia may be preventable, UsAgainstAlzheimer’s convened a workgroup of national experts to develop new recommendations that primary care clinicians and general neurologists can use to initiate primary prevention conversations with their patients about cognitive decline. Few resources address steps that clinicians can take in their routine care to help patients reduce risk. Some relevant resources provide excellent guidance but tend to be more focused on early detection or slowing disease progression rather than primary prevention. The Risk Reduction Workgroup (RRWG) was convened to help address the need for clinicians to know how to discuss cognitive decline with their patients. The workgroup aligned on 11 recommendations for primary care clinicians and general neurologists. In addition the RRWG provide considerations for implementing the recommendations in clinical practice. The recommendations are mindful of social determinants of health, account for cultural differences, and are designed for general accessibility. This effort is part of a broader initiative by UsAgainstAlzheimer’s to address risk-reduction for cognitive decline and early interventions. Under the guidance of a multidisciplinary Provider Leadership Group consisting of representatives from some of the nation's largest health provider serving organizations, three independent workgroups are developing guidance and tools to assist providers in their clinical practice and improve health outcomes for patients at-risk for Alzheimer's and related dementias.

combinations between Black and White older adults. The current study assesses within-and between-group heterogeneity in the prevalence and correlates of MCC combinations to advance health equity research. We utilize a sample of 16,757 Black and White older adults drawn from the 2014 wave of the Health and Retirement Study. Respondents were categorized into one of 32 MCC combination groups. Depressive symptoms and self-rated memory were calculated separately for Black and White respondents across each of the 32 groups. Chi-square tests, t-tests, and ANCOVAs were used to compare differences. Black and White respondents differed significantly in the prevalence of 14 out of 32 MCC combinations. Within-group differences were found such that 45% of Black respondents experiencing only Lung Disease met criteria for clinical depression; this rate is similar to Black respondents experiencing Diabetes + Heart Condition + Hypertension + Lung Disease (44.5%). Between-group differences revealed that Black respondents experiencing Arthritis + Diabetes + Hypertension had worse self-rated memory than White counterparts (MB = 3.24, MW = 3.13; two sample t[1139]= -2.04, p < .05; Cohen's d = 0.13). Additional findings are presented, and theoretical and practical implications for this work are discussed.

PREDICTING SYMPTOM SEVERITIES IN MIDDLE-AGED AND OLDER ADULTS WITH ARTHRITIS AND MULTIMORBIDITY
Wenhui Zhang, Emory University, Atlanta, Georgia, United States Introduction: Uncertainties increase with disease guideline-driven decision-making for older adults as their numbers of chronic conditions and functional limitations increase. A national study found that people with arthritis plus ≥ one other chronic condition have reported significantly higher social participation restriction, serious psychological distress, and work limitation than those with ≥two non-arthritis chronic conditions. However, how arthritis comorbidities contribute to the symptoms such as pain, fatigue, sleep, depression, anxiety, and cognitive abilities that chronically impair people's daily functioning remain unexplored.
Purpose: To explore how arthritis comorbidities predict the symptom severities of pain interference, fatigue, sleep disturbance, depression, anxiety, and cognitive abilities among community-dwelling middle-aged and older adults. Method: 140 community people aged over 50 with arthritis and multimorbidity were recruited. Stepwise regressions predicted the PROMIS symptoms of pain interference, fatigue, sleep disturbance, depression, anxiety, and cognitive abilities with arthritis type and 18 comorbidities measured by the Functional Comorbidity Index checklist after controlling for demographics.
Discussion: Comorbidities and socio-demographics, especially income, impact symptom experiences of people aging with arthritis and multimorbidity. Future studies should explore the pathogenesis among arthritis, comorbidities, and symptoms for tailored intervention while disclosing health disparities associated with the arthritis multimorbidity.

CANNABIS USE AND SUBJECTIVE COGNITIVE DECLINE AMONG MIDDLE-AGED AND OLDER ADULTS Maritza Dowling, George Washington University -School of Nursing, Washington, District of Columbia, United States
Cannabis is the most commonly-used drug in the US, with older adults being the fastest-growing group of users. National surveys among 50+ adults found poorer executive function among current or past cannabis users, but better performance with daily users. However, there is little evidence linking levels of cannabis use and subjective cognitive decline (SCD) among middle-age and older adults. This study sought to examine the association between levels of cannabis use in the past 30 days and SCD during the past 12 months using Behavioral Risk Factor Surveillance System (BRFSS) data (2016-2019) from 45+ individuals while controlling for demographics, chronic conditions, exercise, general and mental health. Logit models with SCD as outcome were estimated using complex survey weights. Multiple group analyses examined differences across age groups: 45-64 vs. 65+. Levels of cannabis use in the past 30 days were categorized as: no use, 1-4 days, 5-20 days; and 21-30 days. Adjusted results indicated that those who reported no cannabis use were from 35% to 47% less likely to report SCD compared to cannabis users at all levels: 1-4 days (OR=0.65, 95%CI=0.46, 0.92); 5-20 days (OR=0.53, 95%CI=0.36,0.78); 21-30 days (OR=.61, 95%CI=0.45,0.83). In multi-group analyses, levels of cannabis use effects on SCD remained statistically significant in the 45-64 age group, but not in the 65+ group. Further research targeting SCD is needed to design interventions particularly for middle-age cannabis users whose health has been compromised by disease or age-related vulnerabilities and are at greater risk for adverse cognitive outcomes from cannabis use. As much as 40% of dementia cases can be attributed to modifiable risk factors (Livingston et al., 2020). Much of that risk-reduction can be accomplished by changing behavior in midlife. In light of the emerging evidence that dementia may be preventable, UsAgainstAlzheimer's convened a workgroup of national experts to develop new recommendations that primary care clinicians and general neurologists can use to initiate primary prevention conversations with their patients about cognitive decline. Few resources address steps that clinicians can take in their routine care to help patients reduce risk. Some relevant resources provide excellent guidance but tend to be more focused on early detection or slowing disease progression rather than primary prevention. The Risk Reduction Workgroup (RRWG) was convened to help address the need for clinicians to know how to discuss cognitive decline with their patients. The workgroup aligned on 11 recommendations for primary care clinicians and general neurologists. In addition the RRWG provide considerations for implementing the recommendations in clinical practice. The recommendations are mindful of social determinants of health, account for cultural differences, and are designed for general accessibility. This effort is part of a broader initiative by UsAgainstAlzheimer's to address risk-reduction for cognitive decline and early interventions. Under the guidance of a multidisciplinary Provider Leadership Group consisting of representatives from some of the nation's largest health provider serving organizations, three independent workgroups are developing guidance and tools to assist providers in their clinical practice and improve health outcomes for patients at-risk for Alzheimer's and related dementias. Medicare beneficiaries with cognitive impairment are more likely to access home health care than those without such impairment, and an estimated 1 in 3 Medicare home health patients has diagnosed dementia. However, recent changes to the Medicare home health payment system do not adjust for patients' cognitive impairment. To the extent that cognitive impairment prompts higher intensity care, this could create a financial disincentive for providers serving this patient population. We draw on a nationally representative sample of 1,214 (weighted n=5,856,333) community-living Medicare beneficiaries who received home health care between 2011-2016. We measure care intensity by the number and type of visits received during an index home health care episode. We model care intensity as a function of patient cognitive impairment during the episode, measured via clinician reports in standardized patient assessment data. In propensity score adjusted, multivariable models holding all covariates at their means, home health patients with identified cognitive impairment received a significantly greater number of visits. During the index home health episode, cognitively impaired patients received an additional 2.82 total visits (95% CI: 1.32-4.31; p<0.001), 1.39 nursing visits (95% CI: 0.49-2.29; p=0.003), 0.72 physical therapy visits (95% CI: 0.06-1.39; p=0.03), and 0.60 occupational therapy visits (95% CI: 0.15-1.05; p=0.01). Findings suggest that recent changes to Medicare home health care reimbursement do not reflect the more intensive care needs of patients with cognitive impairment, and may threaten access to care for these individuals.

RISK FACTORS FOR COGNITIVE DECLINE IN OLDER ADULTS IN PUERTO RICO: ASSESSING BIAS FROM SAMPLE ATTRITION
Brian Downer, 1 Caitlin Pope, 2 Tyler Bell, 3 Sadaf Milani, 1 Ross Andel, 4 and Michael Crowe, 5 , 1. University of Texas Medical Branch,Galveston,Texas,United States,2. University of Kentucky,Lexington,Kentucky,United States,3. University of California San Diego,La Jolla,California,United States,4. University of South Florida,Tampa,Florida,United States,5. University of Alabama at Birmingham,Birmingham,Alabama,United States Many risk factors for cognitive decline are associated with mortality and are common among older adults who cannot complete a survey interview. Our objective was to compare analyses of risk factors for cognitive decline among older adults in Puerto Rico with and without accounting for sample attrition. Data came from the Puerto Rican Elderly: Health Conditions Study. Our sample included 3,437 participants interviewed in 2002/03. Cognitive function was measured using the Mini-Mental Caban (MMC). The outcome was the change in MMC score between 2002/03 and 2006/07. Logistic regression was used to estimate inverse probability weights for being interviewed in 2006/07 (n=3,028) and completing the MMC at follow-up (n=2,601). Linear regression models were used to assess the association between stroke, hypertension, diabetes, smoking status, and cognitive decline with and without the IPWs. In the unweighted analysis, stroke was associated with a significantly greater decline in cognition (b=-0.62, standard error [SE]=0.30, p=0.04). Hypertension (b=-0.02, SE=0.12, p=0.84), diabetes (b=-0.22, SE=0.13, p=0.10) and being a current (b=0.05, SE=0.22, p=0.84) or former smoker (b=0.05, SE=0.14, 0.74) were not associated with cognitive decline in the unweighted analysis. The results were similar when including the IPW for mortality (stroke b=-0.63; hypertension b=-0.03; diabetes: b=-0.20; current smoker: b=0.08; former smoker: b=0.07) and having completed the MMC at follow-up (stroke b=-0.58; hypertension b=-0.03; diabetes: b=-0.20; current smoker: b=0.03; former smoker: b=0.09). These findings indicate that stroke is a risk factor for cognitive decline among older Puerto Rican adults even after accounting for selective attrition. Lina Ma, Yaxin Zhang, Pan Liu, and Yun Li, Xuanwu Hospital, Capital Medical University, National Research Center for Geriatric Medicine, Beijing, Beijing, China (People's Republic) Background: The disease concept is increasingly being replaced by a functional approach to address the healthcare needs of the older people. WHO proposed the Integrated Care for Older People (ICOPE) screening tool to identify older people with priority conditions associated with declines in intrinsic capacity (IC). Very few evidence on the clinical utility of the ICOPE tool is available.